Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, December 10, 2008

Nap Time!

The Resident Coddling Movement (RCM) has just about reached its nadir of absurdity. Recently, the Institute of Medicine (whoever the hell they are) submitted a report recommending that residents ought not to work more than 16 consecutive hours without a break. This, the latest salvo in the work hour reform crusade, supplements previous ACGME mandates such as the 80 hour work week and the prohibition of working more than 30 hours consecutively (already adopted by most residency programs). The Institute cites new "research" unequivocally proving that medical errors rise exponentially past this 16 hour threshold.

The problem is that when you are on call, you are required to spend the night in the hospital. That means the math doesn't add up. Let's say you come into the hospital for rounds at 6am. If you are on call that day, your 16 hour limit will expire at around 10 or 11 pm. So how are you supposed to fulfill your 30 hour obligation? Well, the geniuses at the Institute of Ludicrous Medicine propose that on call residents take a mandatory 5 hour nap. That's right. Nap time. They actually use the word "nap" without a bit of irony or tongue in cheek knowingness. Grown adults in their late twenties, serving an apprenticeship as they try to learn the nuances of one of the toughest jobs on earth, will potentially now be required to take a little nappy so they don't get too sleepy-poo. According to the report, these 5 hour naps will be "monitored". Rumors are also swirling regarding whether or not resident "blankies" will be supplied by hospitals.

Now excuse me for being an out of touch, old school pain in the arse. But this is frankly embarassing. I'm embarassed for these people. I've already rambled on before about the value of spending time in the hospital as a trainee. The best lessons I ever learned as a surgical resident all occured after midnight. The middle of the night disasters, and my responses to them, are what made me the surgeon I am today. But I digress. Something is amiss in America. Wall Steet is in shambles. Ford and GM are on the verge of collapse. Jobs are vanishing overseas. This country is in a tough spot. From a health care perspective, we are on the verge of implementing an all-inclusive system that will require more doctors and more of an effort from health professionals to make it work. What does it say for us, for this younger generation, if our primary concern is legislating less work and less dedication into the training of our future physicians. It compromises us. It's disgraceful and ignominious. Residency isn't a "hazing ritual" as the RCM would like everyone to believe. Who gives a damn how they train residents in Denmark? Certainly it's grueling and exhausting and sometimes you come home and pass out on the couch with a half eaten pan of mac and cheese on your belly. But it's a system that made American medicine the best in the world. There's a reason that shahs and kings and foreign dignitaries have come to Mayo Clinic and MD Anderson and Johns Hopkins for their surgery or medical care over the years. Someday, when I'm ill or in pain and I need medical care, I hope I can rely on these younger doctors who have learned their trade under less taxing circumstances....

3rd year GS resident here. Our only hope is thatthe ACGME chooses not to adopt the IOM's "recommendations", at least the bit about the nap.

As far as how "other countries" train their residents, the IOM report has a nice comparison chart showing how much better the hours are in France and the UK. What they neglect to mention is that in the UK (from what I have been told), a general surgery residency is 8-12 years long.

No thanks. I'll be tired for my 5 years. And I'll take ownership of my patients and refuse to refer to my hours in the hospital as a "shift". When I worked at McDonalds, I worked "shifts".

Ironic thing is that it was easier to nap back in the 120hr/week days. 36 hr mark was when I'd start seein the little green men, and go to the only place I could get some alone time, the John! The Residents lounge was no good cause there'd always be some loudmouth talkin about whether it was pre or post renal oliguria...Anesthesia has the right idea though, outta there by 8am post call even if you got bed sores from sleepin 14 hrs...

As an intern I find these suggestions absolutely scary and humiliating. When I've worked in an ICU for 30 hours I don't go home and nap (need I say no sleep happened, didn't think so). It makes me worse for the next day. So this mandatory 5 hour "nap?" will make me better? If I can get some sleep in the hospital, I will take it - but don't mandate it to me. Seeing patients improve or worsen through your interactions and your judgements definitely trumps sleepy time. Having admitted a patient who is then handed off only to be again handed back who then will be handed off again at the end of 30 hours so you can be rested? Dumb as stool.

"Although the situations will very rarely arise, as a physician, you will deal with crisis situations. The first time you're in a hospital for over 40 hours should not be after you become board certified. "

On rounds this AM i saw the rarest of all animals. I did not take a photo so i am not sure any of you will believe it. But it is true, i saw a POST CALL resident. Never seen anymore this dirty, smelly, disheveled mammal was identified. What has it all come to.

Who gets to be the nap police? Are you going to stand over me and make sure I sleep? Or will I be forced into a call room with a computer so I can get some work done in peace? And whom will they hire to do my work for the 5 hours I'm out of commission? As an intern, I think this is an extremely dumb idea.

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